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ACR–AIUM–SIR–SRU Practice Parameter for the Performance Of The American College of Radiology, with more than 30,000 members, is the principal organization of radiologists, radiation oncologists, and clinical medical physicists in the United States. The College is a nonprofit professional society whose primary purposes are to advance the science of radiology, improve radiologic services to the patient, study the socioeconomic aspects of the practice of radiology, and encourage continuing education for radiologists, radiation oncologists, medical physicists, and persons practicing in allied professional fields. The American College of Radiology will periodically define new practice parameters and technical standards for radiologic practice to help advance the science of radiology and to improve the quality of service to patients throughout the United States. Existing practice parameters and technical standards will be reviewed for revision or renewal, as appropriate, on their fifth anniversary or sooner, if indicated. Each practice parameter and technical standard, representing a policy statement by the College, has undergone a thorough consensus process in which it has been subjected to extensive review and approval. The practice parameters and technical standards recognize that the safe and effective use of diagnostic and therapeutic radiology requires specific training, skills, and techniques, as described in each document. Reproduction or modification of the published practice parameter and technical standard by those entities not providing these services is not authorized. Revised 2017 (Resolution 17)* ACR–AIUM–SIR–SRU PRACTICE PARAMETER FOR THE PERFORMANCE OF PHYSIOLOGIC EVALUATION OF EXTREMITY ARTERIES PREAMBLE This document is an educational tool designed to assist practitioners in providing appropriate radiologic care for patients. Practice Parameters and Technical Standards are not inflexible rules or requirements of practice and are not intended, nor should they be used, to establish a legal standard of care1 For these reasons and those set forth below, the American College of Radiology and our collaborating medical specialty societies caution against the use of these documents in litigation in which the clinical decisions of a practitioner are called into question. The ultimate judgment regarding the propriety of any specific procedure or course of action must be made by the practitioner in light of all the circumstances presented. Thus, an approach that differs from the guidance in this document, standing alone, does not necessarily imply that the approach was below the standard of care. To the contrary, a conscientious practitioner may responsibly adopt a course of action different from that set forth in this document when, in the reasonable judgment of the practitioner, such course of action is indicated by the condition of the patient, limitations of available resources, or advances in knowledge or technology subsequent to publication of this document. However, a practitioner who employs an approach substantially different from the guidance in this document is advised to document in the patient record information sufficient to explain the approach taken. The practice of medicine involves not only the science, but also the art of dealing with the prevention, diagnosis, alleviation, and treatment of disease. The variety and complexity of human conditions make it impossible to always reach the most appropriate diagnosis or to predict with certainty a particular response to treatment. Therefore, it should be recognized that adherence to the guidance in this document will not assure an accurate diagnosis or a successful outcome. All that should be expected is that the practitioner will follow a reasonable course of action based on current knowledge, available resources, and the needs of the patient to deliver effective and safe medical care. The sole purpose of this document is to assist practitioners in achieving this objective. 1Iowa Medical Society and Iowa Society of Anesthesiologists v. Iowa Board of Nursing, 831 N.W.2d 826 (Iowa 2013) Iowa Supreme Court refuses to find that the ACR Technical Standard for Management of the Use of Radiation in Fluoroscopic Procedures (Revised 2008) sets a national standard for who may perform fluoroscopic procedures in light of the standard’s stated purpose that ACR standards are educational tools and not intended to establish a legal standard of care. See also, Stanley v. McCarver, 63 P.3d 1076 (Ariz. App. 2003) where in a concurring opinion the Court stated that “published standards or guidelines of specialty medical organizations are useful in determining the duty owed or the standard of care applicable in a given situation” even though ACR standards themselves do not establish the standard of care. PRACTICE PARAMETER 1 Physiologic Evaluation of Extremity Arteries I. INTRODUCTION The clinical aspects contained in specific sections of this practice parameter (Introduction, Indications, Specifications of the Examination, and Equipment Specifications) were developed collaboratively by the American College of Radiology (ACR), the American Institute of Ultrasound in Medicine (AIUM), the Society of Interventional Radiology (SIR), and the Society of Radiologists in Ultrasound (SRU). Recommendations for physician requirements, written request for the examination, procedure documentation, and quality control vary among the organizations and may be addressed by each separately. This practice parameter has been revised to assist physicians and allied health care professionals performing a nonimaging physiologic examination of the extremity arteries. Although it is not possible to detect every abnormality with physiologic testing, following this practice parameter will maximize the detection of abnormalities of arterial blood supply to the extremities. II. INDICATIONS/CONTRAINDICATIONS Indications for the examination include, but are not limited to: 1. Evaluation of exercise-induced limb pain (claudication) [1] 2. Assessment of digital or extremity ulceration, gangrene, and/or pain at rest [1,2] 3. Follow-up of surgical and endovascular procedures [3] 4. Evaluation of wound healing potential [1] 5. Preprocedure assessment of patients with chronic kidney disease requiring dialysis [4,5] 6. Evaluation of cold sensitivity or discoloration of extremities or digits [6] 7. Evaluation of suspected thoracic outlet syndrome [6] 8. Evaluation of suspected steal distal to an arteriovenous fistula or graft [7,8] 9. Preoperative assessment for arterial harvesting [9,10] 10. Assessment for the presence of peripheral vascular disease as part of an assessment of overall atherosclerosis burden [2,11,12] 11. Preoperative assessment for renal transplantation There are no absolute contraindications for this examination. III. QUALIFICATIONS AND RESPONSIBILITIES OF PERSONNEL Core Privileging: This procedure is considered part of or amendable to image-guided core privileging. Each organization will address this section in its document. ACR language is as follows: See the ACR–SPR–SRU Practice Parameter for Performing and Interpreting Diagnostic Ultrasound Examinations [13]. IV. WRITTEN REQUEST FOR THE EXAMINATION Each organization will address this section in its document. ACR language is as follows: The written or electronic request for a physiologic evaluation of extremity arteries should provide sufficient information to demonstrate the medical necessity of the procedure and allow for its proper performance and interpretation. Documentation that satisfies medical necessity includes 1) signs and symptoms, 2) relevant history (including known diagnoses), and/or 3) prior imaging. Additional information regarding the specific reason for the procedure or a provisional diagnosis would be helpful and may at times be needed to allow for the proper performance and interpretation of the procedure. PRACTICE PARAMETER 2 Physiologic Evaluation of Extremity Arteries The request for the procedure must be originated by a physician or other appropriately licensed health care provider. The accompanying clinical information should be provided by a physician or other appropriately licensed health care provider familiar with the patient’s clinical problem or question and consistent with the state scope of practice requirements. (ACR Resolution 35, adopted in 2006) V. SPECIFICATIONS OF THE EXAMINATION Physiologic tests are indirect tests. Results are used to infer the presence or absence of disease and its severity. Specific locations in the arterial tree are less directly assessed with physiologic techniques as compared with duplex ultrasound. See the ACR–AIUM–SRU Practice Parameter for the Performance of Peripheral Arterial Ultrasound Using Color and Spectral Doppler [14] for duplex evaluation of the arteries. Duplex Doppler ultrasound permits direct assessment of the arterial segments that may be involved with disease. The physiologic examination may be done at 1 level only (eg, the ankles) or at multiple levels of the extremity. Whether done at 1 level or at multiple levels, the examination should be bilateral when possible so that flow in the 2 limbs can be compared. Physiologic testing of the extremities should include pulse volume recordings (PVRs) or continuous wave (CW) Doppler waveforms at the ankle or wrist to allow the accuracy of the ankle-brachial index (ABI) at the ankle to be internally validated. This is particularly helpful in cases of non-compressible calcified arteries. The examination is best performed in a warm room so that the effects of peripheral vasoconstriction
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